Chapter 66: Shock, Sepsis, and Multiple Organ Dysfunction Syndrome
1. A 78-kg patient with septic shock has a urine output of 30 mL/hr for the past 3 hrs. The
P is 120/minute and the central venous pressure and pulmonary artery wedge pressure are
low. Which order by the HCP will the nurse question?
a. Give PRN furosemide (Lasix) 40 mg IV.
b. Increase normal saline infusion to 250 mL/hr.
c. Administer hydrocortisone (Solu-Cortef) 100 mg IV.
d. Titrate norepinephrine (Levophed) to keep systolic BP >90 mm Hg.
ANS: A
2. A nurse is caring for a patient with shock of unknown etiology whose hemodynamic
monitoring indicates BP 92/54, P 64, and an elevated pulmonary artery wedge pressure.
Which collaborative intervention ordered by the HCP should the nurse question?
a. Infuse normal saline at 250 mL/hr.
b. Keep head of bed elevated to 30 degrees.
c. Hold nitroprusside (Nipride) if systolic BP <90 mm Hg.
d. Titrate dobutamine (Dobutrex) to keep systolic BP >90 mm Hg.
ANS: A
3. 19-yr-old patient with massive trauma and possible spinal cord injury is admitted to the
ED. Which assessment finding by nurse will help confirm a diagnosis of neurogenic shock?
a. Inspiratory crackles.
b. Cool, clammy extremities.
c. Apical heart rate 45 beats/min.
d. Temperature 101.2 F (38.4 C).
ANS: C
4. An older patient with cardiogenic shock is cool and clammy and hemodynamic
monitoring indicates a high systemic vascular resistance (SVR). Which intervention should
the nurse anticipate doing next?
a. Increase the rate for the dopamine (Intropin) infusion.
b. Decrease the rate for the nitroglycerin (Tridil) infusion.
c. Increase the rate for the sodium nitroprusside (Nipride) infusion.
d. Decrease the rate for the 5% dextrose in normal saline (D5/.9 NS) infusion.
ANS: C
5. After receiving 2L NS, the central venous pressure for a patient who has septic shock is
10 mmHg, but the BP is still 82/40 mm Hg. The nurse will anticipate an order for
a. nitroglycerine (Tridil).
b. norepinephrine (Levophed).
c. sodium nitroprusside (Nipride).
d. methylprednisolone (Solu-Medrol).
ANS: B
6. To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with
systemic inflammatory response syndrome (SIRS), which assessment will the nurse
perform?
a. Auscultate bowel sounds.
b. Palpate for abdominal pain.
c. Ask the patient about nausea.
d. Check stools for occult blood.
ANS: D
7. A patient with cardiogenic shock has the following vital signs: BP 102/50, P 128, R 28.
The pulmonary artery wedge pressure (PAWP) is increased and cardiac output is low. The
nurse will anticipate an order for which medication?
a. 5% human albumin
b. Furosemide (Lasix) IV
c. Epinephrine (Adrenalin) drip
d. Hydrocortisone (Solu-Cortef)
ANS: B
8. The ED RN receives report that a patient involved in a MVA is being transported to the
facility with an estimated arrival in 1 min. In prep for the patients arrival, RN will obtain
a. hypothermia blanket.
b. lactated Ringers solution.
c. two 14-gauge IV catheters.
d. dopamine (Intropin) infusion.
ANS: C
9. Which finding is the best indicator that the fluid resuscitation for a patient with
hypovolemic shock has been effective?
a. Hemoglobin is within normal limits.
b. Urine output is 60 mL over the last hour.
c. Central venous pressure (CVP) is normal.
d. Mean arterial pressure (MAP) is 72 mm Hg.
ANS: B
10. Which intervention will the nurse include in the plan of care for a patient who has
cardiogenic shock?
a. Check temperature every 2 hours.
b. Monitor breath sounds frequently.
c. Maintain patient in supine position.
d. Assess skin for flushing and itching.
ANS: B
11. Norepinephrine (Levophed) has been prescribed for a patient who was admitted with
dehydration and hypotension. Which patient data indicate that the nurse should consult
with the health care provider before starting the norepinephrine?
a. The patients central venous pressure is 3 mm Hg.
b. The patient is in sinus tachycardia at 120 beats/min.
c. The patient is receiving low dose dopamine (Intropin).
d. The patient has had no urine output since being admitted.
ANS: A
12. A nurse is assessing a patient who is receiving a nitroprusside (Nipride) infusion to treat
cardiogenic shock. Which finding indicates that the medication is effective?
a. No new heart murmurs
b. Decreased troponin level
c. Warm, pink, and dry skin
d. Blood pressure 92/40 mm Hg
ANS: C
13. Which assessment information is most important for the nurse to obtain to evaluate
whether treatment of a patient with anaphylactic shock has been effective?
a. Heart rate
b. Orientation
c. Blood pressure
d. Oxygen saturation
ANS: D
14. Which data collected by the nurse caring for a patient who has cardiogenic shock
indicate that the patient may be developing multiple organ dysfunction syndrome?
a. The patients serum creatinine level is elevated.
b. The patient complains of intermittent chest pressure.
c. The patients extremities are cool and pulses are weak.
d. The patient has bilateral crackles throughout lung fields.
ANS: A
15. A patient with septic shock has a BP of 70/46 mm Hg, P 136, R 32, T 104 F, and BG 246
mg/dL. Which intervention ordered by the HCP should the nurse implement first?
a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.
ANS: A
16. When the nurse educator is evaluating the skills of a new RN caring for patients
experiencing shock, which action by the new RN indicates a need for more education?
a. Placing the pulse oximeter on the ear for a patient with septic shock
b. Keeping the head of the bed flat for a patient with hypovolemic shock
c. Increasing the nitroprusside (Nipride) infusion rate for a patient with a high SVR
d. Maintaining the room temperature at 66 to 68 F for a patient with neurogenic shock
ANS: D
17. The nurse is caring for a patient who has septic shock. Which assessment finding is
most important for the nurse to report to the health care provider?
a. Blood pressure (BP) 92/56 mm Hg
b. Skin cool and clammy
c. Oxygen saturation 92%
d. Heart rate 118 beats/minute
ANS: B
18. pt admitted to ED for shock of unknown etiology. The 1st action by the RN should be to
a. administer oxygen.
b. obtain a 12-lead electrocardiogram (ECG).
c. obtain the blood pressure.
d. check the level of consciousness.
ANS: A
19. During change-of-shift report, the nurse is told that a patient has been admitted with
dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding
is most important for the nurse to report to the health care provider?
a. New onset of confusion
b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities
ANS: A
20. A patient who has been involved in a MVA arrives in the ED with cool, clammy skin;
tachycardia; and hypotension. Which intervention ordered by the HCP should the nurse
implement first?
a. Insert two large-bore IV catheters.
b. Initiate continuous electrocardiogram (ECG) monitoring.
c. Provide oxygen at 100% per non-rebreather mask.
d. Draw blood to type and crossmatch for transfusions.
ANS: C
21. The patient with neurogenic shock is receiving a phenylephrine (Neo-Synephrine)
infusion through a RFA IV. Which assessment finding obtained by the RN indicates a need
for immediate action?
a. The patients heart rate is 58 beats/minute.
b. The patients extremities are warm and dry.
c. The patients IV infusion site is cool and pale.
d. The patients urine output is 28 mL over the last hour.
ANS: C
22. The following interventions are ordered by the HCP for a patient who has respiratory
distress and syncope after eating strawberries. Which will the nurse complete first?
a. Start a normal saline infusion.
b. Give epinephrine (Adrenalin).
c. Start continuous ECG monitoring.
d. Give diphenhydramine (Benadryl).
ANS: B
23. Which finding about a patient who is receiving vasopressin (Pitressin) to treat septic
shock is most important for the nurse to communicate to the health care provider?
a. The patients urine output is 18 mL/hr.
b. The patients heart rate is 110 beats/minute.
c. The patient is complaining of chest pain.
d. The patients peripheral pulses are weak.
ANS: C
24. After change-shift report in the progressive care unit, who should the RN care for 1st?
a. Patient who had an inferior myocardial infarction 2 days ago and has crackles in the lung bases
b. Patient with suspected urosepsis who has new orders for urine and blood cultures and
antibiotics
c. Patient who had a T5 spinal cord injury 1 week ago and currently has a heart rate of 54 bpm
d. Patient admitted with anaphylaxis 3 hours ago who now has clear lung sounds and a blood
pressure of 108/58 mm Hg
ANS: B
Chapter 68: Emergency and Disaster Nursing
1. During the primary assessment of a victim of a MVA, the RN determines that the patient
is breathing and has an unobstructed airway. Which action should the nurse take next?
a. Palpate extremities for bilateral pulses.
b. Observe the patients respiratory effort.
c. Check the patients level of consciousness.
d. Examine the patient for any external bleeding.
ANS: B
2. During the primary survey of a patient with severe leg trauma, the RN observes that the
patients left pedal pulse is absent and leg is swollen. Which action will the nurse take next?
a. Send blood to the lab for a complete blood count.
b. Assess further for a cause of the decreased circulation.
c. Finish the airway, breathing, circulation, disability survey.
d. Start normal saline fluid infusion with a large-bore IV line.
ANS: D
3. After the return of spontaneous circulation following the resuscitation of a patient who
had a cardiac arrest, therapeutic hypothermia is ordered. Which action will the nurse
include in the plan of care?
a. Apply external cooling device.
b. Check mental status every 15 minutes.
c. Avoid the use of sedative medications.
d. Rewarm if temperature is <91 F (32.8 C).
ANS: A
4. A patient who is unconscious after a fall from a ladder is transported to the ED by
emergency medical personnel. During the primary survey of the patient, the nurse should
a. obtain a complete set of vital signs.
b. obtain a Glasgow Coma Scale score.
c. ask about chronic medical conditions.
d. attach a cardiac electrocardiogram monitor.
ANS: B
5. A 19-year-old is brought to the ED with multiple lacerations and tissue avulsion of the
left hand. When asked about tetanus immunization, the patient denies having any previous
vaccinations. The nurse will anticipate giving
a. tetanus immunoglobulin (TIG) only.
b. TIG and tetanus-diphtheria toxoid (Td).
c. tetanus-diphtheria toxoid and pertussis vaccine (Tdap) only.
d. TIG and tetanus-diphtheria toxoid and pertussis vaccine (Tdap).
ANS: D
6. A patient who has experienced blunt abdominal trauma during a MVA is complaining of
increasing abdominal pain. The nurse will plan to teach the patient about the purpose of
a. peritoneal lavage.
b. abdominal ultrasonography.
c. nasogastric (NG) tube placement.
d. magnetic resonance imaging (MRI).
ANS: B
7. A patient with hypotension and an elevated temp after working outside on a hot day is
treated in the ED. The nurse determines that discharge teaching has been effective when
the patient makes which statement?
a. I will take salt tablets when I work outdoors in the summer.
b. I should take acetaminophen (Tylenol) if I start to feel too warm.
c. I should drink sports drinks when working outside in hot weather.
d. I will move to a cool environment if I notice that I am feeling confused.
ANS: C
8. A 22-year-old patient who experienced a near drowning accident in a local pool, but now
is awake and breathing spontaneously, is admitted for observation. Which assessment will
be most important for the nurse to take during the observation period?
a. Auscultate heart sounds.
b. Palpate peripheral pulses.
c. Auscultate breath sounds.
d. Check pupil reaction to light.
ANS: C
9. When planning the response to the potential use of smallpox as an agent of terrorism, the
ED nurse manager will plan to obtain adequate quantities of
a. vaccine.
b. atropine.
c. antibiotics.
d. whole blood.
ANS: A
10. When rewarming a patient who arrived in the ED with a temperature of 87 F (30.6C),
which assessment indicates that the nurse should discontinue active rewarming?
a. The patient begins to shiver.
b. The BP decreases to 86/42 mm Hg.
c. The patient develops atrial fibrillation.
d. The core temperature is 94 F (34.4 C).
ANS: D
11. When assessing an older patient admitted to the ED with a broken arm and facial
bruises, the nurse observes several additional bruises in various stages of healing. Which
statement or question by the nurse is most appropriate?
a. Do you feel safe in your home?
b. You should not return to your home.
c. Would you like to see a social worker?
d. I need to report my concerns to the police.
ANS: A
12. A 20-year-old patient arrives in the ED several hours after taking 25 to 30
acetaminophen (Tylenol) tablets. Which action will the nurse plan to take?
a. Give N-acetylcysteine (Mucomyst).
b. Discuss the use of chelation therapy.
c. Start oxygen using a non-rebreather mask.
d. Have the patient drink large amounts of water.
ANS: A
13. A triage nurse in a busy ED assesses a patient who complains of 7/10 abdominal pain
and states, I had a temp of 103.9 F (39.9 C) at home. The nurses first action should be to
a. assess the patients current vital signs.
b. give acetaminophen (Tylenol) per agency protocol.
c. ask the patient to provide a clean-catch urine for urinalysis.
d. tell the patient that it will 1 to 2 hours before being seen by the doctor.
ANS: A
14. The ED triage nurse is assessing 4 victims involved in a mva. Which patient has the
highest priority for treatment?
a. A patient with no pedal pulses.
b. A patient with an open femur fracture.
c. A patient with bleeding facial lacerations.
d. A patient with paradoxic chest movements.
ANS: D
15. The following interventions are part of the ED protocol for a patient who has been
admitted with multiple bee stings to the hands. Which action should the nurse take first?
a. Remove the patients rings.
b. Apply ice packs to both hands.
c. Apply calamine lotion to any itching areas.
d. Give diphenhydramine (Benadryl) 50 mg PO.
ANS: A
16. Gastric lavage and administration of activated charcoal are ordered for an unconscious
patient who has been admitted to the ED after ingesting 30 lorazepam (Ativan) tablets.
Which action should the nurse plan to do first?
a. Insert a large-bore orogastric tube.
b. Assist with intubation of the patient.
c. Prepare a 60-mL syringe with saline.
d. Give first dose of activated charcoal.
ANS: B
17. A 54-year-old patient arrives in the ED after exposure to powdered lime at work.
Which action should the nurse take first?
a. Obtain the patients vital signs.
b. Obtain a baseline complete blood count.
c. Decontaminate the patient by showering with water.
d. Brush off any visible powder on the skin and clothing.
ANS: D
18. An unresponsive 79-year-old is admitted to the ED during a summer heat wave. The
patients core temp is 105.4 F (40.8 C), BP 88/50, and P 112. The nurse initially will plan to
a. apply wet sheets and a fan to the patient.
b. provide O2 at 6 L/min with a nasal cannula.
c. start lactated Ringers solution at 1000 mL/hr.
d. give acetaminophen (Tylenol) rectal suppository.
ANS: A
19. A patient is admitted to the ED after falling through the ice while ice skating. Which
assessment will the nurse obtain first?
a. Heart rate
b. Breath sounds
c. Body temperature
d. Level of consciousness
ANS: B
20. Following an earthquake, patients are triaged by emergency medical personnel and are
transported to the ED. Which patient will the nurse need to assess first?
a. A patient with a red tag
b. A patient with a blue tag
c. A patient with a black tag
d. A patient with a yellow tag
ANS: A
21. Family members are in the patients room when the patient has a cardiac arrest and the
staff start resuscitation measures. Which action should the nurse take next?
a. Keep the family in the room and assign a staff member to explain the care given and answer
questions.
b. Ask the family to wait outside the patients room with a designated staff member to provide
emotional support.
c. Ask the family members about whether they would prefer to remain in the patients room or
wait outside the room.
d. Tell the family members that patients are comforted by having family members present during
resuscitation efforts.
ANS: C
22. A 28-year-old patient who has deep human bite wounds on the left hand is being treated
in the urgent care center. Which action will the nurse plan to take?
a. Prepare to administer rabies immune globulin (BayRab).
b. Assist the health care provider with suturing of the bite wounds.
c. Teach the patient the reason for the use of prophylactic antibiotics.
d. Keep the wounds dry until the health care provider can assess them.
ANS: C
23. The urgent care center protocol for tick bites includes the following actions. Which
action will the nurse take first when caring for a patient with a tick bite?
a. Use tweezers to remove any remaining ticks.
b. Check the vital signs, including temperature.
c. Give doxycycline (Vibramycin) 100 mg orally.
d. Obtain information about recent outdoor activities.
ANS: A
1. When preparing to cool a patient who is to begin therapeutic hypothermia, which
intervention will the nurse plan to do (select all that apply)?
a. Assist with endotracheal intubation.
b. Insert an indwelling urinary catheter.
c. Begin continuous cardiac monitoring.
d. Obtain an order to restrain the patient.
e. Prepare to give sympathomimetic drugs.
ANS: A, B, C
2. The ED nurse is initiating therapeutic hypothermia in a patient who has been
resuscitated after a cardiac arrest. Which actions in the hypothermia protocol can be
delegated to an experienced LPN (select all that apply)?
a. Continuously monitor heart rhythm.
b. Check neurologic status every 2 hours.
c. Place cooling blankets above and below patient.
d. Give acetaminophen (Tylenol) 650 mg per nasogastric tube.
e. Insert rectal temperature probe and attach to cooling blanket control panel.
ANS: C, D, E
Chapter 24: Burns
1. When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes
that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What
term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: B
2. On admission to the burn unit, a patient with an approximate 25% TBSA burn has the
following initial lab results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8
mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate
taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
3. A patient is admitted to the burn unit with burns to the head, face, and hands. Initially,
wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are
audible. What is the best action for the nurse to take?
a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patients respiratory rate.
d. Reposition the patient in high-Fowlers position and reassess breath sounds.
ANS: B
4. A patient with severe burns has crystalloid fluid replacement ordered using the Parkland
formula. The initial volume of fluid to be administered in the first 24 hrs is 30,000 mL. The
initial rate of administration is 1875 mL/hr. After the first 8 hrs, what rate should the nurse
infuse the IV fluids?
a. 350 mL/hour
b. 523 mL/hour
c. 938 mL/hour
d. 1250 mL/hour
ANS: C
5. During the emergent phase of burn care, which assessment will be most useful in
determining whether the patient is receiving adequate fluid infusion?
a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.
ANS: D
6. A patient has just been admitted with a 40% TBSA burn injury. To maintain adequate
nutrition, the nurse should plan to take which action?
a. Insert a feeding tube and initiate enteral feedings.
b. Infuse total parenteral nutrition via a central catheter.
c. Encourage an oral intake of at least 5000 kcal per day.
d. Administer multiple vitamins and minerals in the IV solution.
ANS: A
7. While the patients fullthickness burn wounds to the face are exposed, what is the best
nursing action to prevent cross contamination?
a. Use sterile gloves when removing old dressings.
b. Wear gowns, caps, masks, and gloves during all care of the patient.
c. Administer IV antibiotics to prevent bacterial colonization of wounds.
d. Turn the room temperature up to at least 70 F (20 C) during dressing changes.
ANS: B
8. A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and
hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.
ANS: B
9. A patient with circumferential burns of both legs develops a decrease in dorsalis pedis
pulse strength and numbness in the toes. Which action should the nurse take?
a. Notify the health care provider.
b. Monitor the pulses every 2 hours.
c. Elevate both legs above heart level with pillows.
d. Encourage the patient to flex and extend the toes on both feet.
ANS: A
10. Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn
injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the
medication?
a. Bowel sounds
b. Stool frequency
c. Abdominal distention
d. Stools for occult blood
ANS: D
11. The nurse is reviewing the MAR on a patient with partial-thickness burns. Which
medication is best for the nurse to administer before scheduled wound debridement?
a. Ketorolac (Toradol)
b. Lorazepam (Ativan)
c. Gabapentin (Neurontin)
d. Hydromorphone (Dilaudid)
ANS: D
12. A young adult patient who is in the rehabilitation phase after having deep partialthickness face and neck burns has a nursing diagnosis of disturbed body image. Which
statement by the patient indicates that the problem is resolving?
a. Im glad the scars are only temporary.
b. I will avoid using a pillow, so my neck will be OK.
c. I bet my boyfriend wont even want to look at me anymore.
d. Do you think dark beige makeup foundation would cover this scar on my cheek?
ANS: D
13. The nurse caring for a patient admitted with burns over 30% of the body surface
assesses that urine output has dramatically increased. Which action by the nurse would
best ensure adequate kidney function?
a. Continue to monitor the urine output.
b. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d. Prepare the patient for discharge from the burn unit.
ANS: A
14. A patient with burns covering 40% TBSA is in the acute phase of burn treatment.
Which snack would be best for the nurse to offer to this patient?
a. Bananas
b. Orange gelatin
c. Vanilla milkshake
d. Whole grain bagel
ANS: C
15. A patient has just arrived in the ED after an electrical burn from exposure to a highvoltage current. What is the priority nursing assessment?
a. Oral temperature
b. Peripheral pulses
c. Extremity movement
d. Pupil reaction to light
ANS: C
16. An employee spills industrial acids on both arms and legs at work. What is the priority
action that the occupational health nurse at the facility should take?
a. Remove nonadherent clothing and watch.
b. Apply an alkaline solution to the affected area.
c. Place cool compresses on the area of exposure.
d. Cover the affected area with dry, sterile dressings.
ANS: A
17. A patient who has burns on the arms, legs, and chest from a house fire has become
agitated and restless 8 hrs after being admitted to the hospital. Which action should the
nurse take first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.
ANS: D
18. A patient arrives in the ED with facial and chest burns caused by a house fire. Which
action should the nurse take first?
a. Auscultate the patients lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringers solution.
d. Administer the ordered hydromorphone (Dilaudid).
ANS: A
19. A patient with extensive electrical burn injuries is admitted to the ED. Which
prescribed intervention should the nurse implement first?
a. Assess oral temperature.
b. Check a potassium level.
c. Place on cardiac monitor.
d. Assess for pain at contact points.
ANS: C
20. 8 hrs after a thermal burn covering 50% of a patients TBSA the nurse assesses the
patient. Which information would be a priority to communicate to the HCP?
a. Blood pressure is 95/48 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 108.
d. Urine output is 20 mL per hour for the past 2 hours.
ANS: D
21. Which patient should the nurse assess first?
a. A patient with smoke inhalation who has wheezes and altered mental status
b. A patient with full-thickness leg burns who has a dressing change scheduled
c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain
d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500
mL/hour
ANS: A
22. Which patient is most appropriate for the burn unit charge nurse to assign to a RN who
has floated from the hospital medical unit?
a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral
feedings.
b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb
aspiration
c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial
autograft to the chest
d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partialthickness facial burns
ANS: A
23. A patient who was found unconscious in a burning house is brought to the ED by
ambulance. The nurse notes that the patients skin color is bright red. Which action should
the nurse take first?
a. Insert two large-bore IV lines.
b. Check the patients orientation.
c. Assess for singed nasal hair and dark oral mucous membranes.
d. Place the patient on 100% oxygen using a non-rebreather mask.
ANS: D
24. The nurse is reviewing lab results on a patient who had a large burn 48 hrs ago. Which
result requires priority action by the nurse?
a. Hematocrit 53%
b. Serum sodium 147 mEq/L
c. Serum potassium 6.1 mEq/L
d. Blood urea nitrogen 37 mg/dL
ANS: C
25. The charge RN observes the following actions being taken by a new nurse on the burn
unit. Which action by the new nurse would require an intervention by the charge nurse?
a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound.
b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C).
c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a
dressing change.
d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic
patients serum glucose is elevated.
ANS: A
26. Which nursing action is a priority for a patient who has suffered a burn injury while
working on an electrical power line?
a. Obtain the blood pressure.
b. Stabilize the cervical spine.
c. Assess for the contact points.
d. Check alertness and orientation.
ANS: B
27. Which action will the nurse include in the plan of care for a patient in the rehabilitation
phase after a burn injury to the right arm and chest?
a. Keep the right arm in a position of comfort.
b. Avoid the use of sustained-release narcotics.
c. Teach about the purpose of tetanus immunization.
d. Apply water-based cream to burned areas frequently.
ANS: D
28. A young adult patient who is in the rehabilitation phase 6 months after a severe face
and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal
again. Which response by the nurse is best?
a. Most people recover after a burn and feel satisfied with their lives.
b. Its true that your life may be different. What concerns you the most?
c. It is really too early to know how much your life will be changed by the burn.
d. Why do you feel that way? You will be able to adapt as your recovery progresses.
ANS: B